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Best practices for absorbable suspension suture technology

Article-Best practices for absorbable suspension suture technology

Authors of a new expert consensus share their extensive experience treating more than 500 patients and lessons learned with Silhouette InstaLift absorbable suspension suture technology. The consensus, published June 2018 in the Journal of Drugs in Dermatology, updates aesthetic providers in several areas, including patient selection, pre-treatment planning, suture placement, post-procedure care, adverse events and combining InstaLift treatment with energy-based devices, neurotoxins and fillers.

FDA cleared for use in the midface, Silhouette InstaLift (Sinclair Pharma) non-surgically repositions descended facial tissue. Over time, the technology’s absorbable suture and cones, made of poly lactic-co-glycolic acid (PLGA) and poly L lactic acid (PLLA), help re-volumize and recontour the face. The authors write patients usually don’t need retreatment for 18 months to two years, and often retreatment requires fewer sutures.  

While absorbable suspension sutures don’t achieve what a surgical facelift can, the minimally invasive option bridges a gap for patients who may not be candidates for surgery or don’t want an invasive procedure and need volume restoration beyond what fillers can provide.

Ideal patients have strong bony projections, skin thick enough to prevent suture palpability, as well as enough skin elasticity to accommodate repositioning. On the other hand, patients whose skin is thin, has little elasticity, is sun damaged or has extensive wrinkling tend not to be ideal candidates. That said, the authors note that mature patients can benefit from tissue repositioning and recontouring with the Silhouette InstaLift. Their results might be less dramatic given the diminished ability to produce collagen that comes with aging.

One update since a consensus paper on the safety and efficacy of absorbable suspension sutures published in the Journal of Drugs in Dermatology, July 2017, is that thicker-skinned patients might be better candidates for the Silhouette InstaLift than first thought. The authors report that providers can achieve good outcomes if they use enough sutures, and if patients’ skin is mobile and pliable.

Critically Important Considerations

The authors point to “critically important” considerations that they’ve experienced in the past year: Proper technique is vital and providers should seek training with a device representative or through continuing medical education options.

The authors prefer the 8-cone suture for all facial applications.

Providers need to use a sufficient number of sutures to optimally reposition descended tissue. For example, four or more sutures on each side of the face give the mechanical benefit required to reposition tissue in multiple anatomical areas. The authors recommend providers tailor the technique to address individual patient’s needs, while offering general recommendations to avoid under correction.

While cheeks and nasolabial folds are on-label indications for the technology, providers should consider jowls and the jawline as a part of absorbable suspension suture treatment.

The authors emphasize that providers must orient the suture’s opposing cones in a straight line, versus a U or V formation. The approach, called straight-line vector planning, ensures lasting and effective tissue positioning and maximum collagen regeneration, while the other formations not only reduce overall lifting ability but also increase the chances of suture displacement. 

Providers should inject 1% lidocaine with epinephrine at the entry and exit sites — not into the suture paths. Patients need to be able to feel pain in the suture paths because that could indicate that the needle is in the incorrect plane, according to the authors.

Providers should place sutures in a straight line, perpendicular to the skin that requires lifting, to maximize mechanical lift and anchoring.

After Procedure Care & Adverse Events

Compared to the 2017 consensus, this paper makes slightly less restrictive recommendations about post-procedure care.  For example, providers might consider not instructing patients to apply ice at home in the 24 hours after their procedures because patients often apply too much pressure when icing at home.

“Within the last 12 months, the adverse event rate per 106,810 devices sold is 0.006%,” the authors write.

Swelling is likely but usually dissipates within three days.

Minor bleeding normally occurs with treatment. But providers should immediately treat post-procedure bleeding or profuse bleeding during treatment, as these are rare.

The authors recommend that providers consider not recommending that patients who are on blood thinners stop those medications a week prior to suture placement because the potential risk associated with interrupting the therapy outweighs the higher chance of bruising.

Finally, providers can use energy-based devices, neurotoxins or fillers to augment the rejuvenating results from the Silhouette InstaLift, but timing is important. Energy-based treatments are best used six weeks before suture placement, for example. Providers shouldn’t use other modalities where they’ve placed suspension sutures on the day of Silhouette InstaLift treatment, but they can use those modalities in adjacent or distinctly different areas of the face, they write.